South London Healthcare NHS Trust

Earl Howe Excerpts

Thursday 31st January 2013 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, with the leave of the House I shall now repeat a Statement made in another place earlier today by my right honourable friend the Secretary of State for Health on the subject of South London Healthcare NHS Trust. The Statement is as follows:

“With permission, Mr Speaker, I would like to make a Statement on the future of South London Healthcare NHS Trust.

The NHS exists to provide patients with the highest levels of care and compassion and it does so in a way that is more equitable than any other country in the world: comprehensive care, free at the point of need. But to be true to those values, different parts of the NHS need to be financially sustainable. Financial problems left unaddressed become clinical problems, not least because money used to fund deficits cannot be used for patient care.

The South London Healthcare NHS Trust is the most financially challenged in the country, with a deficit of £65 million per annum. It currently spends some £60 million a year, or 16% of its annual income, to service two PFI contracts signed in 1998. For this and other reasons, repeated local attempts to resolve the financial crisis at the trust have failed. As a result, the trust is losing more than £1 million every week. In the three years since it was formed in 2009, it has generated a deficit of £153 million, a figure that will rise to more than £200 million by the end of this financial year—a huge amount money that has to be diverted away from front-line patient care.

So, after consulting the trust, its commissioners and the London Strategic Health Authority, my predecessor as Health Secretary, my right honourable friend the Leader of the House, instituted the special administration process, which includes a period of intense local engagement. Matthew Kershaw, former chief executive of Salisbury NHS Foundation Trust, was appointed as the trust special administrator in July 2012. I would like to put on record my thanks to him and his team for his exceptionally detailed and thorough work.

Mr Kershaw had the extremely difficult task of finding a clinically and financially sustainable way forward for the South London Healthcare NHS Trust. Reluctantly, he concluded that only by looking beyond the boundaries of the trust to the wider health community was he able to put forward a viable solution. I support that analysis.

I received his recommendations on 7 January. Six of his seven recommendations were as follows: first, that over the next three years, all three hospitals within the trust—Queen Elizabeth Hospital in Woolwich, Queen Mary’s in Sidcup and the Princess Royal in Bromley—make the full £74.9 million of efficiencies he has identified; secondly, that Queen Mary’s in Sidcup be transferred to Oxleas NHS Foundation Trust and developed into a hub for the provision of health and social care in Bexley; thirdly, that all vacant or poorly utilised premises be vacated, and sold where possible; fourthly, that the Department of Health pay the additional annual funds to cover the excess costs of the PFI buildings at the Queen Elizabeth and Princess Royal hospitals; and, fifthly, that the South London Healthcare Trust be dissolved, with each of its hospitals taken over by neighbouring NHS and foundation trusts. Sixthly, to aid implementation, he further recommended that the Department of Health write off the accumulated debt of the trust so as not to set the new trusts up to fail; that the Department of Health provide additional funds to cover the implementation of his recommendations; and that a programme board be appointed under an independent chair, reporting to Sir David Nicholson as chief executive of the NHS Commissioning Board, to ensure the changes are effectively delivered. I have accepted each of these recommendations in full.

As a consequence, he also recommended that services be reconfigured beyond the confines of South London NHS Trust, across all of south-east London. This part of his recommendation included reducing the number of A&E departments across the area from five to four; replacing the A&E department at University Hospital Lewisham with a non-admitting urgent care centre; reducing the number of obstetrician-led maternity units from five to four; downgrading the current obstetrician-led maternity unit at University Hospital Lewisham to a stand-alone midwife-led birthing centre—each obstetrician-led maternity unit would also have a midwife-led birthing centre—co-locating paediatric emergency and inpatient services with the four A&E units, with paediatric urgent care provided at Lewisham, Guy’s and Queen Mary’s hospitals; and finally, that University Hospital Lewisham should become a centre for non-complex elective procedures, such as hip and knee replacements, to serve the entire population of south-east London.

The public campaign surrounding services at Lewisham Hospital has highlighted just how important it is to the local community. I respect and recognise the sense of unfairness that people feel because their hospital has been caught up in the financial problems of its neighbour. However, solving the financial crisis next door is also in the interests of the people of Lewisham, because they, too, depend on the services that are currently part of South London Healthcare Trust. None the less, I understand their very real concerns about how any changes could affect their access to vital health services. These concerns are echoed by Lewisham CCG and many clinicians at Lewisham Hospital. I have had in-depth discussions with the honourable Members representing those affected, who have reflected those concerns to me. As a result, I asked the NHS medical director, Professor Sir Bruce Keogh, to review the recommendations and to consider three things: first, whether there was sufficient clinical input into the development of the recommendations; secondly, whether there is a strong case that the recommendations will lead to improved patient care in the local area; and, thirdly, whether they are underpinned by a clear clinical evidence base, as set out in the third of the four tests for reconfigurations.

On the matter of clinical input, a highly experienced clinical advisory group, led by a local GP, Dr Jane Fryer, and including eight trust medical directors, six clinically qualified CCG chairs, the London Ambulance Service medical director, the local director for trauma and three directors of nursing, supported the trust special administrator.

Further scrutiny and challenge was provided by an external clinical panel, which included representatives from the Royal Colleges of Midwives and of Obstetricians and and Gynaecologists. The panel was chaired by Professor Chris Welsh, SHA medical director for the Midlands and East of England. Both groups included respected national and local clinicians, built on years of previous work in this area and held a series of clinical workshops in August and September of last year. Sir Bruce was satisfied that there had, indeed, been sufficient clinical input.

On the issue of better care and clinical evidence, the recommendations provide for the adoption, for the first time in south-east London, of the 2012 pan-London standards for acute care. These are the standards that all six local CCGs have said they want to commission for both emergency and maternity care. These standards define the best available clinical practice and set the bar higher than that provided by most other acute providers in England.

Sir Bruce agreed with the TSA that the adoption of these standards, which mean improving the level of care available to the residents of south-east London, could not be achieved without a reduction in the number of sites delivering acute in-patient care. Such a reduction will enable the necessary concentration of resources and senior clinical staff. A similar approach has already led to significant improvements in stroke, major trauma and cardiovascular disease services throughout London, saving hundreds of lives.

For both emergency and maternity care, Sir Bruce found no evidence that patients would be put at risk through increased journey times. The whole population of south-east London will continue to be within 30 minutes of a blue light transfer to an A&E department, with the typical journey time being, on average, only one minute longer. Accessing consultant-led maternity services will increase journey times on average by two to three minutes by private or public transport. Sir Bruce concluded, therefore, that there should be no impact on the quality of care from the small increase in travel time.

On the issue of maternity services, the expert clinical panel advising the TSA was not willing to support the increased risk to patients of having an obstetrician-led unit at Lewisham without intensive care services. As achieving the London-wide clinical standards will be possible only with the consolidation of the number of sites with these facilities, Sir Bruce supports the proposal for this unit to be replaced with a free-standing midwife-led unit at Lewisham hospital. This will continue to deal with at least 10% of existing activity and potentially up to 60%. Thirty-six million pounds of additional investment has been earmarked to ensure that there is sufficient capacity at the other sites.

Turning now to the emergency care proposals, Sir Bruce was concerned that the recommendation for a non-admitting urgent care centre at Lewisham may not lead, in all cases, to improved patient care. While those with serious injury or illness would be better served by a concentration of specialist A&E services, this would not be the case for those patients requiring short, relatively uncomplicated treatments or a temporary period of supervision. To better serve these patients, who would often be frail and elderly and arrive by non-blue light ambulances, Sir Bruce recommends that Lewisham hospital should retain a smaller A&E service with 24/7 senior emergency medical cover.

With these additional clinical safeguards, and the impact that this is likely to have on patient and clinician behaviour, Sir Bruce estimates that the new service could continue to see up to three-quarters of those currently attending Lewisham A&E.

Allowing Lewisham to retain its A&E would help to reduce the level of increased demand at hospitals with larger A&E services, while an additional £37 million of investment will further expand services at these hospitals for more serious conditions. Sir Bruce advised that patients with those more serious conditions should now be taken to King’s, Queen Elizabeth, Bromley or St Thomas’s, not for financial reasons but to increase their chances of survival.

On the issue of paediatric care, Sir Bruce recognised the high-quality paediatric services at Lewisham and that any replacement would have to offer even better clinical outcomes and patient experience. His opinion is that this is possible but dependent on very clear protocols for primary ambulance conveyance, a walk-in paediatric urgent care service at Lewisham and rapid transfer protocols for any sick children who would be better treated elsewhere. He is clear that this will require careful pathway planning and need to be a key focus of implementation.

With these caveats, Sir Bruce was content to assert that there is a strong case for saying that the recommendations are likely to lead to improved care for the residents of south-east London and that they are underpinned by clear clinical evidence. He believes that overall these proposals, as amended, could save up to 100 lives every year through higher clinical standards.

Yesterday, 30 January, as no viable alternative plan has been put forward, and in the light of Sir Bruce’s opinion I decided to accept the recommendations of the trust special administrator, subject to the amendments suggested by Sir Bruce. It is important to be clear that my acceptance of these recommendations is conditional on Monitor approving the proposals relating to foundation trusts and on my department negotiating an appropriate level of transitional funding with organisations such as King’s partners.

Due to the size of the task, there is a significant level of risk associated with achieving the identified savings. I recognise that the additional clinical safeguards I have put in place will marginally increase these financial risks but, on balance, I have made the judgment that this is worth it if it means that local patients are reassured they will gain from an additional better service, rather than losing their A&E.

I believe the amended proposals meet the four tests required for local reconfigurations. I am therefore content for the process to now proceed to implementation and I expect the South London Healthcare NHS Trust to be dissolved by no later than 1 October 2013.

The implementation of these recommendations will be challenging and complex. It needs to be planned for carefully and will not happen overnight. I call on all organisations, hospitals and commissioners to offer their full support during the coming years to achieve the ambition of these proposals for the benefit of the people of south-east London. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, the noble Baroness’s comments echo very closely those made in another place by her right honourable friend the Shadow Secretary of State. I am disappointed that they do, because she seems not to have taken account of anything that the Statement contained. First, I heard no recognition that there is a serious problem to be addressed in south London. A deficit of £1 million a week is a serious matter in any terms. The deficit means that resources, whether people or money but mostly both, are being applied inefficiently. That plays into concerns about equity, which is one of the fundamental principles of the NHS. Not to acknowledge that we had a major problem there and that funds were being diverted into servicing debt that should have been applied to patient care was regrettable.

Secondly, there was no acknowledgement that the process that we had adopted was that laid down by the then Government—of whom she was a distinguished member—in the 2009 Act that amended the 2006 Act. That process is quite deliberately couched in a way designed to bring a rapid conclusion to what, by definition, is bound to be a serious if not intractable situation such as this—a curtailed process that involves public consultation but not the kind of consultation that flows from reconfiguration decisions, which are locally led.

In this case, it was our judgment that only the unsustainable provider regime was applicable, after repeated attempts by local clinicians, both commissioners and providers, to find a way of resolving the problem by looking at the difficulties faced by the trust. In the judgment of the TSA, it was a necessary and consequential part of the solution to look more widely than the trust itself, and that is what we did.

I heard a grudging recognition that the decision to retain an A&E department at Lewisham was welcome. I am glad that the noble Baroness welcomed that. We took that decision, which was not one that the trust special administrator recommended, because we listened to local opinion and to Sir Bruce Keogh’s advice. It was clear that, in some cases, it would not serve the best interests of those presenting at A&E to have to be moved to another hospital. Therefore, we took the decision that there should now be 24/7 cover in an A&E department and the capacity to admit patients from A&E. Neither of those things was recommended by the TSA, but this is what we now propose.

The noble Baroness said that this decision clearly reflected that finance took precedence over patient safety and care. I simply do not agree. Finance is, of course, a major consideration, but the fundamental thing we wanted to assure ourselves of—and this is one of the four tests that my right honourable friend Andrew Lansley put in place—was that there should be clear evidence of clinical benefit. Not only have we had two expert panels advising the TSA about this, we have had reassurance from Sir Bruce Keogh as well. I suggest to the noble Baroness that these are not people whom Ministers have somehow nobbled or interfered with. We have stayed absolutely separate from the process, as is right and proper. This has been an independent process and the results are as I have indicated.

The clinical justification for these proposals is there. All four tests that we put in place—the four tests for any change of services—have been passed, not only in terms of local consultation but also in terms of support from clinicians and of patient choice. On one level, one could argue that any service change that seeks to drive up clinical quality by consolidating clinical skills on fewer sites diminishes choice. Nevertheless, choice is not just about being able to choose a provider; it is about choosing the right care in the right place. At the moment, the London-wide clinical standard that was mentioned in the Statement is not being adhered to in any of the hospitals in that part of the world, so one could argue that the choice of provider is very limited when it comes to choosing the right quality care. It is from the fact that commissioners want to commission that higher standard that all the rest flows. To say that this is being driven purely by finance is incorrect.

By their nature, these decisions are very difficult. The job of a Secretary of State—and I believe that my right honourable friend has performed it admirably, both dispassionately and conscientiously—is to look at the best interests of the population in a region. He has done that and taken independent advice, and I hope that noble Lords will recognise that when they look more carefully at these recommendations.

[Lord Tomlinson]

My Lords, I join in the thanks offered to the noble Earl for repeating the Statement. One has the feeling that, for someone so highly respected in this House, his heart was not really in the repetition.

Lewisham hospital is a local hospital which produces excellent local care—and I declare an interest as someone who uses its services. What the Minister has announced today is that he is not going to make the cuts quite as bad as they were—not quite as extensive. But, in effect, we are still having a very good service penalised in order to provide resources for the failures. Can I ask two specific questions arising from the Statement? At one point it states that,

“a non-admitting Urgent Care Centre at Lewisham may not lead, in all cases, to improved patient care”.

How does the Minister square that with some of the other statements made about the principles on which this reorganisation is based? With two further tranches of money—£36 million and £37 million—provided to the other sites which need to be improved, I ask him to comment on what the Secretary of State said at the end, namely that,

“there is a significant level of risk associated with achieving the identified savings. I recognise that the additional clinical safeguards I have put in place will marginally increase these financial risks but on balance”—

basically, “I think it might be all right”. Is this not another example of wishing being given a higher priority than factual decision-making?

[Earl Howe]

My Lords, perhaps I may put on the record my own recognition that Lewisham hospital is an excellent hospital. There is no question about that and there has never been any question about it. The hospital provides good care for local people and it is highly valued. Only this afternoon I had one noble Lord from my own Benches telephoning me to tell me of his personal experience of Lewisham hospital and its excellent maternity care.

The noble Lord asked me two specific questions. He quoted the Statement where at one point it was made clear that a non-admitting urgent care unit at Lewisham would not improve patient care. That is the precise reason why Sir Bruce Keogh recommended something different; namely, an admitting A&E unit with 24/7 cover. He looked at the recommendation and was not satisfied with it in terms of risks to patients. I hope that that is helpful to the noble Lord because I think he misconstrued what I was saying.

On the question of risk, any set of assumptions that relies on hypotheses around patient flows in the future and clinical referral decisions has to be, by its very nature, uncertain. It is the view of the trust special administrator and the review of my right honourable friend that the assumptions underpinning these decisions are reasonable, and that was backed up by Sir Bruce Keogh. But the noble Lord has a point because the implementation of these recommendations is going to be key, and that is why the TSA has recommended a programme board to oversee the implementation of these recommendations over the next few years. It is absolutely essential that commissioners and the providers in that area buy in to these proposals. We believe that they will, but it is important that if the financial risk is to be minimised, we get as close as possible to the forecast and predictions that the TSA has set out.

[Lord Kennedy of Southwark]

My Lords, I want to draw the attention of noble Lords to my declaration of interests in respect of Lewisham hospital. I would like to pay tribute to the staff of the hospital who serve the community so well, and the local residents involved in the save Lewisham A&E campaign for the fantastic campaign they have run. It is supported by local GPs, local businesses and Millwall Football Club. We have a great hospital that is supported and valued locally. In the past two years the ConDem Government have spent £12 million on funding the refurbishment of the Lewisham A&E unit. We have a fantastic children’s A&E unit. That refurbishment was finished only in April last year, yet today they have downgraded our maternity and A&E services to pay for the failings of a neighbouring trust. Will the noble Earl agree to publish all of the legal advice the Government have received in respect of the decision they have taken today? Can he also tell the House if he has ever visited Lewisham Hospital? I am glad he agrees that it is actually a great hospital. If he has not visited it, will he confirm that he is willing to do so at the earliest opportunity, in the light of his responsibilities for quality and urgent care? Further, can he tell the House what he would have spent the £5 million on?

[Earl Howe]

My Lords, the facilities at Lewisham A&E are indeed very good, and a lot of money has been spent on them. I would hope that the noble Lord will therefore welcome the fact that we are keeping an A&E department open. That department will be comparable with many other A&E departments around the country. It will be a fully functioning department other than for those difficult and critical cases which, by common clinical agreement, need more specialist care where clinical resources can be concentrated. That is increasingly the view of senior clinicians in the royal colleges around London.

The other point that the noble Lord may need to factor in is that many of the services in an area of the country, whether it is London or anywhere else, depend on networks. What we envisage for Lewisham and Woolwich, taken together, is that they will be part of an active network, with staff rotating between the two. There will be an understanding of what each hospital is capable or incapable of doing, and an understanding on the part of ambulance trusts as to where best to take patients. We have already seen the results of that policy. This is not idle speculation. There is proof positive from the decision to decrease the number of acute stroke units in London from 32 to eight; the mortality rate has more or less halved since that decision was taken. So there is clear clinical underpinning.

I note the noble Lord’s understandable regret that Lewisham has been caught up in the problems of its neighbour. However, as the Statement made clear, the people of Lewisham also depend on the services of South London Healthcare Trust, so to say that there is somehow an island of patients who simply go to Lewisham would not be fair.

The noble Lord asked me about publication of the legal advice. I can confirm that the decision of my right honourable friend has been taken in the light of consideration of the legal issues and advice to him that it is lawful. The normal position is that the Government do not publish legal advice; there is a long-standing precedent. However, I can tell him that the legal advice backs up his decision.

[Lord Wills]

I am very grateful—

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[Earl Howe]

If the noble Lord will allow, I will just cover the final point made by his noble friend.

Given the need to reassure local patients that the changes will indeed lead to better outcomes for them, my right honourable friend took the decision proactively to publish Sir Bruce Keogh’s letter to him, setting out his clinical advice, as it has had a large bearing on his decision. So we have been as open as possible about the clinical basis on which this decision has been taken.

[Lord Wills]

I am very grateful to the Minister and apologise for intervening inappropriately. On the question of legal advice, notwithstanding the convention, will he agree that it is open to the Government to waive legal privilege in exceptional circumstances and that this might be such a case, since these are clearly exceptional circumstances?

[Earl Howe]

My advice is that there is no case for waiving that practice. As I said, it is a long-standing principle and indeed the practice of successive Governments that legal advice is given to Ministers in confidence. Therefore I am afraid that I cannot accommodate the noble Lord’s suggestion.

To answer the question asked by the noble Lord, Lord Kennedy, about visiting Lewisham Hospital, I have not done so personally. I try to visit as many hospitals as I can. If I am able to fit Lewisham into my programme, I would be happy to do so.

[Baroness Wheatcroft]

My Lords, I declare an interest—as so many have—in that my three children were all born in Lewisham Hospital. Thus I share the emotional feeling of many that it seems unfair that Lewisham should be penalised for the spendthrift ways of other NHS trusts. However, my understanding is that Sir Bruce was asked to look not at the financial implications but at the patient implications of restructuring. He has done that and is satisfied with the result. One thing he points out is that, in the future, not every hospital would have the capacity to offer intensive care after maternity care. One of my three children needed intensive care. If Lewisham cannot provide the highest of high-tech intensive care, then some hospitals in London will have to. The issue is that, given the high technology that is now coming in to medicine, not every hospital can be a centre of excellence. We have to spread the resource. That means some hospitals will specialise. As somebody who benefited from what was then the best of intensive care, I am very keen to see that London, and in particular south-east London, should be able to offer that. However, I accept that not every hospital that provides maternity services will be able to. Can the Minister tell me whether he can see—because I cannot—any reason why Sir Bruce would have reached the conclusions that he had, in print, if he did not actually believe them?

[Earl Howe]

I am grateful to my noble friend and agree with all that she has said. In making this very difficult decision, my right honourable friend’s primary concern has been to protect outcomes for local patients. Indeed, the logic behind these proposals comes from the clinicians themselves, who came together from across London—way before the TSA was appointed—to develop a series of standards for certain conditions. These are based on the simple principle that a critical mass of highly qualified specialist consultants in one place, on a 24/7 basis, available to see patients within one hour and backed up by the latest medical equipment, will give patients better outcomes. At present, no south-east London hospital meets all the emergency or maternity clinical quality standards. Achieving those standards will mean accommodating acute in-patient care across fewer sites. The result will be that people in south-east London will continue to have much better access to A&E and specialist maternity units than the majority of the population in England, and the prediction is that up to 100 lives a year will be saved by this rearrangement of services. My noble friend has raised a very important point because this is about better patient outcomes.

[Baroness Gould of Potternewton]

My Lords, I want to ask the Minister about the next stages and what happens now. I was interested in the paragraph that says:

“It is important to be clear that my acceptance of these recommendations is conditional on Monitor approving the proposals relating to foundation trusts and on my Department negotiating an appropriate level of transitional funding with organisations such as Kings Partners”.

What is the actual process by which Monitor will now do this? When is it likely to report? When is it likely that the transitional funding will be agreed? What is the process if neither of those things is agreed?

[Earl Howe]

My Lords, the noble Baroness asks some extremely pertinent questions. Matthew Kershaw, the TSA, expects to start a new job as chief executive of Brighton and Sussex University Hospitals NHS Trust in the spring. That will happen before South London Healthcare NHS Trust is dissolved. As we move into the implementation phase, my right honourable friend will use powers in the 2006 Act to appoint a new TSA to provide the management role normally performed by the board of directors. That takes care of the mechanics of management, and the person appointed will of course have to have the necessary skills and experience to lead the trust. The TSA worked closely with both foundation trusts and Lewisham Healthcare NHS Trust to develop his proposals. The trusts are eager for the mergers to go ahead to realise the benefits that I have described. All three trusts are now working towards having signed heads of terms in place that agree the principles of the transaction and set the basis for the final deal.

Looking forward, the organisational changes will almost certainly not occur until somewhere between June and October. Having said that, the trust managers will immediately start making the necessary operational efficiency improvements, as indeed I know they are keen to do. The actual transfers of emergency maternity and paediatric services to other sites is planned to happen in late 2015. That will not be immediate, because it is necessary to spend the funds that I have mentioned to expand the capacity of these other acute centres.

[Baroness Gould of Potternewton]

I am sorry to interrupt the noble Earl, but will he actually answer the question about Monitor and the transitional funding arrangements?

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[Earl Howe]

I apologise. Monitor is an independent body; it will have to look at, as it is duty-bound to do, the effect of these proposals on the foundation trusts concerned—namely, Kings and Oxleas—and whether it is satisfied that all legal requirements are met. The TSA was confident in that regard, but we cannot take it for granted. As regards the transitional funding, I mentioned that all three trusts are now working towards having signed heads of terms in place, and the principles of the transactions and the basis for the final deal will include the financial aspects of the mergers. It is important for the department to work to get the best deal for the taxpayer in these transactions. Although an indicative sum of money has been quoted in the TSA’s report for this, it would be wrong, I think, for the department to commit a precise sum of money at this stage. It is important that as much money as possible is saved by the trusts working through these proposals for themselves, before the department steps in. However, we will step in to do what is necessary to ensure that these proposals are properly implemented.

[Lord Patten]

My Lords, I remember a particularly torrid period of campaigning in Lewisham when in the other place which almost led me to seek the assistance of the A&E department at Lewisham hospital. Does the Minister not agree that on every occasion, however understandable, attachments to institutions and to buildings that have been there for a long time are always trumped by patient outcomes and patient care?

[Earl Howe]

My Lords, my noble friend has raised a very good point. It is entirely understandable for a local Member of Parliament, and local people, to feel an attachment towards a particular building that, for them, represents the best of what the NHS has to offer. However, as my noble friend points out, what really matters in a healthcare economy is the quality of the service delivered to those people. Services can be delivered in a variety of ways. It is the view of local clinicians—five out of the six local CCGs support these proposals—that the TSA’s recommendations will deliver better quality care and will save lives. It is that wider consideration that my right honourable friend has had in mind throughout.